Answer: The 4 chamber view shows the mitral apparatus. The aortic valve is not seen so the portions seen are probably A2 and P2. Medially and posteriorly, during systole, tissue is seen prolapsing into the atrium, and associated with a jet of MR suggestive of prolapse of a portion of the anterior mitral leaflet. Although is could be a vegetation, and i admit more views would have been helpful, it was a flail of A3. When eccentric jets occur, they usually imply excessive movement of leaflet tissue-if the jet is posterior, it is most likely due to anterior prolapse or posterior restriction (as is sometimes seen in ischemic MR) and vice versa.

October 2008Question: Clip #1 is a series of cuts from base to mid-papillary level after coming off CPB following a procedure. Clip #2 shows a deep transgastric view taken at the same time. The first image shows a Doppler cursor placed in the same view as clip #2; the second image shows the CW trace at that time, and the third image shows the same CW cut after certain theraputic maneuvers have been undertaken. Describe what is seen in each instance.

Answer: Clip number 1 has 3 frames; on the left, a mitral annuloplasty ring is seen in short axis; in the middle, the ring is again seen, and during systole some unexpected tissue is seen; on the right is a midpapillary view showing LVH. Clip number 2 shows systolic anterior motion of the anterior mitral leaflet. Image 1 shows a cursor placed through the LVOT; image 2 shows the typical appearance of outflow tract obstruction, a so called "dagger-shapedappearance". This is secondary to underfilling, vasodilating, and increase inotropy. After fluid administration, vasoconstriction, and stopping the inotropes, we are left with a more uniform Doppler signal, which is consistent with an aortic valve prosthetic gradient from aortic valve replacement surgery several years back.

September 2008Question: What abnormality is demonstrated in this surface study?

Answer: This is a surface study of a newborn showing the ascending aorta, the arch, the great vessels, and the descending aorta. Under the aortic arch, the pulmonary artery is seen, Along with the colour Doppler jet indicating flow in the aorta and great vessels, there is continuous flow between the PA and the proximal descending aorta indicating a patent ductus arteriosus (PDA).

Surface Study

August 2008Question: On the basis of the 6 videos and the two images, what abnormality did the patient have, and how was it corrected.

Answer: This patient had a D-transposition of the great arteries with a VSD and pulmonic stenosis, repaired by a Rastelli procedure.

Image 1 and video 1 show RVH secondary to the increased RV work. Video 2 shows parallel orientation of the aortic valve (anterior) and the pulmonic valve (posterior). It is also seen that the pulmonic valve is not opening-it has bee surgically obliterated so that the systemic ventricle stops pumping to the lungs. In figures 3a and 3b the VSD has been patched such that the systemic ventricle now pumps into the aorta.

To re-establish blood flow to the lungs, a valved conduit is placed from the RV to the PA as seen in videos 4a and 4b. The CW in image 4 shows a modest peak gradient of approximately 15mmHg.

Newer surgical techniques are now being used to correct this condition.

July 2008Question: 4 cases of mitral regurgitation are presented. In only one of them is the MR made worse by decreased afterload. Which one?

Answer:

Case 1 is a patient with an inferior wall MI as seen on the EKG. In animation “A”, the basal inferior wall is akinetic, and the papillary muscle does not contract; in fact in some views it looks ruptured. Animation “B” shows a retracted posterior mitral leaflet, with an eccentric jet of MR directed posteriorly. When the posterio papillary muscle was examined at surgery, its head was infracted, and scar tissue was seen on microscopic examination.

Case 2 is a patient with MR secondary to rheumatic mitral stenosis.

Case 3 (CORRECT) is a patient with systolic anterior motion of the anterior mitral leaflet, with outflow tract obstruction with turbulence of systolic flow, and eccentric MR. It is well none that the outflow tract obstruction worsens with vasodilation, as would the mitral deformation with subsequent worsening of MR. All other cases would show improvement of MR.

Case 4 is a patient with a flail posterior mitral leaflet (P2).

Some respondents answered case 1, as they felt that lower BP would comprimise coronary perfusion, increase ischaemia, and worsen MR. The “Q” wave in the EKG, and the thin appearance of the inferior wall suggest that vasodilation would be unlikely to worsen MR; the decreased afterload and improved forward flow would augur well for decreased MR (and this was the case clinically).